A story from the north

By Alison Philp

AIMS Journal, 2009, Vol 21 No 1

Alison Philp shares the story of her birth and complaint outcomes

It is more than a year since my daughter was unceremoniously pulled out of my body on the end of a suction cup and entered the world with a bruise on her head and probably a headache to match. She was plopped onto the stomach of a mother who was feeling both shocked and delighted at her entrance into the world.

It was a problem free pregnancy. We visited our local midwife led unit where we planned to have our daughter and it all seemed to be okay. I received reassurances to all my worries and concerns from the community midwives. I wouldn’t be hurried in the midwife unit, I would have a CD player and a birthing pool available, I would be able to move about and eat. Everybody seemed to totally support my desire for a normal labour and birth without unnecessary interventions and there seemed to be no reason to worry at all.

It was near the end of my pregnancy that my ideas changed. Work had finished and I was busy reading up on labour and bir th. All the information about home births was suddenly available to me. I was also, around this time, advised to have a water birth meeting at the midwife-led unit to discuss safety rules and usage of the pool. I called several times but they were always too busy to see me at the times I could visit (it was 40 minutes away by car). I started to feel that I had made a mistake. I spoke to a midwife in the hospital as I managed to visit to see the pool in the obstetric ward to get some idea of a water birth, and told her I was considering changing my mind and staying at home. She was shocked that I was thinking of changing at such a late stage of pregnancy. When I got home the community midwife called. She advised that my due month was very busy for home births and that I could not be accommodated. I believed her and I blamed myself for not being together enough to sort it out earlier. I thought I would put other mothers at risk if I refused and stayed at home.

When I spontaneously went into labour I waited at home until I was sure I was in established labour. Wearrived in the midwife led unit and were told I was 4cm dilated. I had a birthing pool and a CD player and a midwife that we liked. We were happy. Eight hours later it was a different story. My labour had failed to progress past 7cm for four hours. The midwife informed us that they thought they should break my waters. We trusted her, and we weren’t being offered any alternatives, so we agreed. We were then informed that meconium was present in the amniotic fluid and that we were to be transferred to the obstetric unit.

It was obvious to us as soon as we walked through the doors of the obstetric unit that things were going very wrong in our hopes for a normal, harmonious birth. No CD player was available, there was a bed in the middle of the room that I was instructed to get on and a monitor to which I was attached. The whole environment was clinical. All the things I had dreaded would happen were starting to happen and I just couldn’t stop them. It was all going out of control like a slow motion car crash. I understood that meconium could mean distress and one good thing was that I did feel reassured by the monitor and by the healthy sound of the baby’s heartbeat. Meanwhile however my contractions were getting weaker and weaker.

Two hours later and I was now attached to a drip of syntocinon, a monitor and was sitting on a bed. Throughout the next six hours my partner asked the midwife several times to move my position and she replied that I was in too much pain to move (I asked for air and gas for pain relief.) He felt he couldn’t ask for a different midwife, it just seemed too rude he thought, and so we stuck it out with her. On her way out at the end of the shift she told the new midwife that the mother was fine but she wasn’t sure about the father, a joke at our expense, so much for all the rhetoric about respecting the partner's role during labour!

An hour after the shift change I was aware of the new midwife lifting up my leg and instructing me to push. I had no urge to push and looked at her and did nothing. My partner asked her to go out the room and he suggested that I should not be pushing like that (the NICE guidelines recommend a woman follow her own spontaneous urge to push and if this has no effect to change position frequently and to encourage). The midwife said ‘no it was correct and critical that I should push.’ I tried to do what she said and ‘push into my bum.’ I was in a semi sitting position on the bed. I was strapped up and had a mask over my face for air and gas. It was an hour before my partner finally got the midwife to move me to an upright position.

I was fifteen minutes on my knees, hands over the top of the bed when I became angry at the way things were going. I didn’t want to be ordered to push. I could feel the confusion in my body and knew I needed some privacy, and some space to find my own way of birthing this baby. This is a lot to communicate when you are in labour and all I could summon was a very direct demand that ‘I can’t do this and I am not doing this.’ The midwife looked surprised and a bit crestfallen and then glanced at the clock. I will get the doctor she said. Two minutes later a doctor came in and looked at me on the bed. He seemed to think a bit and then said ‘this is the end.’ To me these words meant the birth was nearly over and I was relieved to hear the end was in sight. He left and then the midwife urged me to ‘push the baby out before the doctor arrives.’ My feelings of relief turned to panic as I realised she was referring to an instrumental delivery. I had been in active second stage for one hour and 30 minutes and upright for only fifteen minutes.

It was only a matter of about two minutes between her saying, ‘push the baby out,’ and the trolleys being wheeled, my legs being lifted into stirrups for the lithotomy position, and the doctor entering with a, very young looking, female senior house officer. My partner and I were told what was going to happen, a ventouse was going to be used. The doctor said he may have to make a ‘small cut.’ I replied ‘if he had to.’ I was not ‘in my gas and air state of mind’ thinking of episiotomy as I had been told antenatally they only do this if absolutely necessary and he was not explaining the necessity nor did he actually say the word ‘episiotomy.’ A brief few seconds later I was cut and the ventouse was being placed on thebaby’s head. The senior house officer stood behind the doctor observing; she was never introduced to us.

Thirteen minutes later and in two contractions our baby was on my stomach and the midwife said ‘Here you go. You had better check you got what you wanted.’ (meaning a boy or a girl.) They asked my partner to cut the cord, ‘wait till it stops pulsating,’ he said…’ ‘It’s already been clamped,’ they told him. He cut it and looked aggrieved that this last thing had also been denied us. We later found out that the midwife had injected me with syntometrine, without consent, and this is why they had clamped it so early. After I had been stitched the doctor left and the midwife commented to me that the vagina didn’t need to be cut and I felt my head spin; why was she saying that? It must have been necessary, mustn’t it?

Our daughter was a beautiful baby. She had two APGAR scores of nine and she weighed six pounds and 14 ounces. We were euphoric about meeting her and for a while the events of her birth paled into insignificance. It was a good few months later that I pieced the story together with a friend. Only then did I admit that there had been someone present in the room who wasn’t introduced to us, that I had been misunderstood by the midwife when I said ‘I can’t do it,’ that there had been no discussion and no informed consent to the ventouse, the syntometrine or the episiotomy. That I had absolutely no idea why things had gone so wrong for us, and that a normal birth had not been possible.

I first spoke to my health visitor who agreed there were points of concern and she made an appointment with the community midwife. The community midwife arrived at our house with a timeline for us to track the events, what happened and why it happened. I found out that there were rules and protocols about rates of dilation in the midwife led unit and that there was a hospital policy time limit on active second stage. I had previously heard, and
read, that there were guidelines in labour rather that strict protocols and rules.

Nobody had mentioned hospital rules or protocols antenatally and so this was all news to me. She also advised (quite wrongly) that to stop the doctor intervening I would really have had to be saying ‘stay away, don’t come near me.’ She agreed that I should have given consent to the syntometrine, especially as I hadspecifically indicated in my records that I wanted a physiological third stage, but she also assured me that I had needed the injection and that in fact everything that took place during my daughter’s birth was ‘best clinical practice.’ She sent a report to her supervisor regarding some of the issues we were unhappy about and asked for a supervisory review.

Three weeks later we received a reply from her supervisor. It was not ‘on our side’ so to speak but was defensive of the hospital and the staff, and mainly dismissive of our concerns that in many instances had not even been either accurately reported or understood by her. The one point it agreed on was that consent should have been obtained for syntometrine and a reminder of the need to obtain consent had been passed to all staff. Her letter also included the statement (or should I say understatement) that she and her colleagues agreed that ‘communication towards the latter part of my labour could have been better.’ In the next few weeks I had, what I can only describe, as a breakdown as I found myself sobbing uncontrollably and not being able to sleep or function normally.

I spoke to the community midwife again to ask if I could talk to someone else in the hospital. We had a tense conversation and she demanded that I ‘accept this was the labour and birth that I had had and that I get on with my life.’ I only wish I could have ‘got on with my life’ instead of having the symptoms of trauma I was experiencing. She also said that my scar (from episiotomy) had healed and that I was fine, when I replied that my mind hadn’t healed she offered to refer me to psychiatric services through my GP. I had however already been to my GP and the counsellor she sent me to was clueless and hadn’t helped at all. I had to find a counsellor privately. An appointment was made by the community midwife for my partner and myself to see my consultant.

The consultant seemed like a nice man and did show concern for my distress. He lost some of his appeal however when I asked him about consent and he joked ‘we can’t have that, we have women in here begging for caesareans.’ He further confounded me by asking if I had been given morphine as if this was a reason not to get consent (even if I been mentally incapacitated by drugs my partner certainly wouldn’t have been and he could have spoken for me). He also started to talk about women in third world countries and how obstetrics had lowered the mortality rate in the developed world. All very interesting but nothing, I felt, to do with the events of my labour. Talking to him did help us get our concerns off our chest and we felt that he understood our distress and that genuinely he cared about our experience which was very heartening after the horrible supervisory review letter and the frosty conversation with the community midwife.

I kept talking to people to debrief and try to find out the facts of my daughter’s birth. I read the NICE guidelines and the WHO guidelines. I talked to AIMS and the NCT and to midwives working for other trusts. I read books such as Birth Crisis by Sheila Kitzinger and Primal Health by Michel Odent. I put in a formal complaint to the hospital and I also wrote to the Local Supervisory Authority for Midwifery Practice. The complaint process took many months and the Supervisory Authority did eventually visit the hospital to discuss my concerns. These are my conclusions:

Home birth
I should never have been refused a home birth for the reasons stated i.e. too many home births were booked that month (there were three home births booked in that month, usually there are one or two. It is still very rare to have a home birth.) The midwife advised me at the booking meeting that I could always change my mind later on if I wanted to but unfor tunately this turned out not to be the case. A woman has the right to choose where to have her baby and can change her mind at any point in her pregnancy, even in labour. No one has the authority to tell a woman where to give birth. I realise that asking late on in pregnancy makes things more difficult for the midwives but they are still legally and duty-bound to attend a home birth if it is requested. It is very telling that home birth transfer rates for first time and other mothers are substantially lower than the transfer rates from a hospital midwife led unit into a consultant unit. Home birth is just more natural, there are no rigid time constraints and there is no risk of the midwives being stressed and overburdened because of a busy ward.

Informed consent
There was no consultation and no informed consent to the ventouse delivery. Through the complaint process it was relayed to me and my partner that the doctor and midwife ‘believed’ that they informed us regarding the need for instrumental delivery and that we were ‘in agreement.’ My hospital records show that there was never any discussion or consent to any of their procedures and my partner and I know that no discussion or informed consent took place. The issue of ‘informed consent’ was later discussed with the Supervisory Authority during her visit. She wrote to me that she had
received assurances from the hospital that ‘the wider midwifery staff have been reminded of their professional accountability in ensuring that a woman’s wishes and consent are received prior to any procedures being under taken.’

Position and mobility
I was in a semi-supine position most of the time during active second stage which greatly contributed to a ‘prolonged second stage.’ Sitting on your pelvis narrows the space available for the baby to be born and does not allow your coccyx to move back and let the baby descend. It also meant that gravity could not contribute to the birth of the baby. The hospital stated that ‘I could have moved position if I had wanted and they are sorry if I was not aware of this.’ It was, however, very clear in all my correspondence to them that my partner had asked many times for help to move my position but had been refused until finally they got me upright the last fifteen minutes. I didn’t realise how ‘out of it’ I would be during the birth and that I would be unable to move myself because of the pain and because of the medical equipment. With hindsight, I should have had a doula present in case I was transferred into an obstetrics ward and ended up pushing in the standard hospital supine position.

Meconium
The presence of meconium with a normal heart rate is not a sign of fetal distress. I feel that this arbitrary time limit of one and a half hours was unwarranted and that as there was no emergency the doctor should never have been called by the midwife (although I am told this is normal practice in this hospital). The doctor sent the assurance that he ‘only had your and your child’s best interests at heart’ and a list of possible ‘serious consequences’ were given to me as a reason for intervening i.e. meconium aspiration syndrome (MAS), hypoxia, uterine rupture and formation of fistulas. The NICE guidelines recommend birth should take place within three hours and so the chance of any of these things happening in one and a half or two hours must be very remote (apart from MAS which can happen at any time but in most cases doesn’t). From talking to other professionals I understand that it was most probably the anxiety/ fear of the midwife and the doctor and their rigid adherence to hospital protocol that lead to the intervention rather than because of any real indication of clinical necessity.

Explanations and choice
There was no consent to the injection of syntometrine to actively remove the placenta. I understand that in an augmented birth it really is necessary to have syntometrine but again I should still have received an explanation and been asked for permission. A full apology has been given for this.

Consideration
The senior house officer was not introduced to us. We have received an apology from her. Her presence at my daughter’s birth presents a grey area. Was she training or was she part of my care? At first I was informed by the community midwife and her supervisor that I was in a teaching hospital and that if I didn’t want trainees present I should have indicated. It does not state anywhere in the hospital booklet about the teaching of doctors (only students.) The hospital complaint department also advised me that ‘doctors don’t come from nowhere.’ I asked the General Medical Council for their guidelines and they advised that they advocate that ‘the patient has the right not to take part in teaching.’ When I passed this guideline to the hospital and told them that I should have been asked if a trainee doctor could be present the SHO’s reasons for being present were changed to a list of duties she could have performed if the need arose and that she was in fact assisting the registrar obstetrician as a part of my care. I am unsure what to believe but although it upset me immeasurably at the time, and for a long time afterwards, (I clearly saw the doctor indicate the cut he made to her) I am willing to accept that she was a part of my care, even if the reasons given seem a bit sketchy (and no more or less than most midwives could do) i.e. mop up blood, hold retractors, assist if things didn’t go smoothly.

The trauma has mostly subsided now due to the skills of a good counsellor and to Emotional Freedom Technique which I practice regularly whenever I feel myself starting to panic or getting upset. I am sure that time will be the best healer of all, together with our beautiful daughter who every day replaces the bad memory of the events surrounding her bir th with many wonderful memories of her childhood.

I am glad I complained about my daughter’s birth as I think complaining does help other women in the future. The hospital advised in the conclusion of their letter to me that ‘they have reflected on the issues I have raised in order to ensure that women in labour are provided with appropriate information and involved in their care.’ The Local Supervisory Authority have also taken the issue of informed consent seriously enough to warrant a visit to the hospital to gain their assurances. I know there are a lot of good midwives working at the unit who do a fantastic job and wouldn’t dream of not practising ‘informed consent, but I would still recommend to anyone not to take a chance on it, if they can. If you really want as good a shot at a ‘normal birth’ as possible either stay at home or if hospital is the preferred, or only choice, then don’t do it without a doula.

I am currently expecting my second baby in May. I have booked a home birth and hired a doula. If I have learned one thing from this experience it is BE INFORMED AND LOOK AFTER YOUR MENTAL HEALTH.